Every finding on record at Tri-County Nursing Home

Based on record review and interview, the facility failed to ensure resident records were accurate for 6 of 10 residents reviewed for medication management, Residents #3, #15, #44, #46, #48, and #61, and for 1 of 3 residents reviewed for change in condition, Resident #4.Findings include: 1) Review of Resident #46's physician order dated 8/18/2025 read, Insulin Glargine-yfgn Subcutaneous Solution Pen-injector 100 unit/ml [milliliter] (Insulin Glargine-yfgn), Inject 45 unit subcutaneously two times a day for DM2 [diabetes mellitus type 2] daily @ [at] 0600 [6:00 AM] and 2100 [9:00 PM], Hold if BG [Blood Glucose] less than 100. Review of Resident #46's Medication Administration Record (MAR) for April 2026 for administration of Insulin Glargine showed code 2 [refused] documented on 4/1/2026 at 6:00 AM and 4/5/2026 at 6:00 AM. Review of Resident #46's nursing progress notes showed no documentation of physician notification of medication refusal on 4/1/2026 and 4/5/2026. Review of Resident #46's physician order dated 4/21/2025 read, Novolog Injection Solution 100 unit/ml (Insulin Aspart), Inject as per sliding scale: if 0-150= 0 units; 151-200= 2 units; 201-250= 4 units; 251-300= 6 units; 301-350= 8 units; 351-400= 10 units; 401+ = 12 units; Greater than 400 Notify MD [Medical Doctor], subcutaneously before meals and at bedtime for DM 2. Review of Resident #46's MAR for March 2026 for administration of Novolog Injection Solution documented a BS of 435 on 3/14/2026 at 4:30 PM, a BS of 459 on 3/21/2026 at 9:00 PM, and a BS of 495 on 3/26/2026 at 11:00 AM. Review of Resident #46's nursing progress notes showed no documentation of physician notification for blood glucose above 400 on 3/14/2026, 3/21/2026, and 3/26/2026. During an interview on 4/8/2026 at 1:10 PM, the Advanced Practice Registered Nurse (APRN) stated, I know that she [Resident #46] will refuse her medications and her insulin. They will text me about that. I know she has had sugars over 400. 2) Review of Resident #48's physician order dated 3/8/2026 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), Inject 31 unit subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy, unspecified. Review of Resident #48's MAR for March 2026 for administration of Insulin Glargine showed code 2 documented on 3/14/2026 at 9:00 PM, code 13 [no insulin required] documented on 3/26/2026, and code 9 [other/see progress notes] documented on 3/31/2026. Review of Resident#48's nursing progress notes showed no physician notification of medication refusal or other progress notes for 3/14/2026, 3/26/2026, and 3/31/2026. Review of Resident #48's eMAR (electronic medication administration record) progress note dated 3/27/2026 at 10:10 PM read, Note Text: Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml Inject 31 unit subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy, unspecified. Patient refused full amount. Requested 15u [units]. 15u given. Review of Resident #48's nursing progress notes for 3/27/2026 showed no physician notification of resident refusal to take prescribed dose. Review of Resident #48's physician orders showed no order dated 3/27/2026 to administer 15 units of Insulin Glargine. Review of Resident #48's eMAR progress note dated 3/28/2026 read, Note Text: Insulin Glargine Subcutaneous Solution Pen-injector 100 units/ml, Inject 31 unit subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy, unspecified. Patient requested to receive half of her long acting insulting dose. I administered 15 units. Review of Resident #48's nursing progress notes for 3/28/2026 showed no physician notification of resident refusal to take prescribed dose. Review of Resident #48's physician orders showed no order dated 3/28/2026 to administer 15 units of Insulin Glargine. Review of Resident #48's nursing progress note dated 3/29/2026 at 8:47 PM read, Note Text: Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml, Inject 31 unit subcutaneously at bedtime related to type 2 diabetes mellitus with diabetic neuropathy, unspecified. Patient requested only 15 units be given. Review of Resident #48's nursing progress notes for 3/29/2026 showed no physician notification of resident refusal to take prescribed dose. Review of Resident #48's physician orders showed no order dated 3/29/2026 to administer 15 units of Insulin Glargine. Review of Resident #48's MAR for April 2026 for administration of Insulin Glargine showed code 2 documented on 4/5/2026 at 9:00 PM. Review of Resident#48's nursing progress notes for 4/5/2026 showed no documentation of physician notification of medication refusal. During an interview on 4/8/2026 at 11:50 AM, the Director of Nursing (DON) stated, All communication with the physicians should be documented either in the eMAR notes or in the progress notes. Ideally that is a good standard of practice. I was not aware that she [Resident #48] was getting half her dose of the insulin on those days. During an interview on 4/8/2026 at 12:02 PM, the Medical Director stated, I am consistently notified about her [Resident #48] blood sugars but was not aware that she was requesting half her dose of insulin. I was not taking call, my nurse practitioner was, so I would call her. During a telephone interview on 4/8/2026 at 1:10 PM, the APRN stated, I was called and notified that she was requesting only half her insulin, and I preferred that she got some if that meant she would refuse the whole dose. I am aware that she refuses her insulin frequently. The staff will text us. 3) Review of Resident #61's physician order dated 9/17/2025 read, Insulin Regular Human Injection Solution Pen-injector 100 units/ml (Insulin Regular (Human)), Inject 5 unit subcutaneously before meals for DM2. Review of Resident #61's MAR for March 2026 for administration of insulin showed code 2 documented on 3/6/2026 at 4:00 PM, on 3/14/2026 at 11:00 AM, on 3/17/2026 at 11:00 AM, on 3/18/2026 at 11:00 AM, and on 3/19/2026 at 4:00 PM. Review of Resident #61's nursing progress notes showed no documentation of physician notification of medication refusals on 3/6/2026, 3/14/2026, 3/17/2026, 3/18/2026 and 3/19/2026. Review of Resident #61's MAR for April 2026 for administration of insulin showed code 2 documented on 4/1/2026 at 11:00 AM and at 4:00 PM, on 4/3/2026 at 11:00 AM, and on 4/5/2026 at 4:00 PM. Review of Resident #61's nursing progress notes showed no documentation of physician notification of medication refusals on 4/1/2026, 4/3/2026 and 4/5/2026. During an interview on 4/8/2026 at 9:40 AM, Staff B, Registered Nurse (RN), stated, We should document when we call a doctor of nurse practitioner when blood sugars are high or when residents refuse medications. 4) Review of Resident #15's physician order dated 1/26/2026 read, Insulin Aspart Injection Solution 100 unit/ml (Insulin Aspart), Inject subcutaneously before meals and at bedtime for DM2. Review of Resident #15's MAR for March 2026 for administration of Insulin Aspart showed code 2 documented at 6:30 AM on 3/1/2026, 3/6/2026, 3/10/2026, 3/11/2026, 3/13/2026, 3/17/2026, 3/24/2026, 3/27/2026, 3/29/2026, and 3/31/2026; at 11:00 AM on 3/3/2026, 3/4/2026, 3/10/2026, 3/13/2026, 3/14/2026, 3/17/2026, 3/19/2026, 3/21/2026, 3/23/2026, 3/24/2026, and 3/26/2026; at 4:30 PM on 3/2/2026, 3/4/2026, 3/7/2026, 3/8/2026, 3/11/2026, 3/13/2026, 3/14/2026, 3/18/2026, 3/19/2026, 3/24/2026, and 3/25/2026; and at 9:00 PM on 3/5/2026, 3/6/2026, 3/12/2026, 3/13/2026, 3/16/2026, 3/24/2026, and 3/26/2026. Further review showed code 7 (Sleeping) documented at 6:30 AM on 3/12/2026, 3/18/2026, and 3/20/2026; at 11:00 AM on 3/1/2026, 3/2/2026, 3/5/2026, 3/9/2026, 3/11/2026, 3/12/2026, 3/18/2026, 3/22/2026, 3/25/2026, 3/27/2026, and 3/31/2026; at 4:30 AM on 3/1/2026, 3/5/2026, 3/10/2026, 3/12/2026, 3/15/2026, 3/17/2026, 3/20/2026, 3/23/2026, 3/26/2026, and 3/31/2026, at 9:00 PM on 3/1/2026, 3/3/2026, 3/8/2026, 3/10/2026, 3/18/2026, 3/20/2026, 3/22/2026, 3/25/2026, and 3/31/2026. Review of Resident #15's MAR for April 2026 for administration of Insulin Aspart showed code 2 documented at 6:30 AM on 4/1/2026, and 4/7/2026; at 11:00 AM on 4/4/2026; at 4:30 PM on 4/4/2026; and at 9:00 PM on 4/3/2026. During an interview on 4/8/2026 at 10:21 AM, Staff D, RN, stated she notified the physician of Resident #15 refusing his medication or was sleeping at the scheduled medication times. Staff D stated she would normally document contacts with the physician in the resident's progress note. During an interview on 4/8/2026 at 9:40 AM, Staff B, RN, stated contacts with the physician should be documented in the resident's progress note. Review of Resident #15's progress notes dated 3/1/2026 through 4/7/2026 showed no documentation indicating nursing staff had notified the physician or nurse practitioner when Resident #15 had either refused his accu-chek and insulin or was sleeping at his scheduled medication times. During an interview on 4/8/2026 at 11:50 AM, the DON stated nurses routinely contact the physician regarding omitted medications and the nursing staff should document contact with the physician regarding omitted medications in the resident's electronic medication record or progress note. During an interview on 4/8/2026 at 12:12 PM, the Medical Director stated the facility staff notified him or the nurse practitioner at all hours of the night and day. 5) During an interview on 4/6/2026 at 9:44 AM, Resident #4's Representative stated, The weekend nurse wasn't able to give me any information about lab results. The facility is just not good at communicating in general. Review of Resident #4's care plan dated 1/27/2026 read, Focus: [Resident #4's name] has impaired cognitive function/thought processes r/t [related to] short-term memory loss and CVA [stroke]. Interventions: Communicate with [Resident #4's name] and her family regarding capabilities and needs. Date Initiated: 03/22/2022. Review of Resident #4' health status note dated 2/26/2026 read, Consultation: referral placed to pulmonology and chest x-ray due to coughing with eating, chest pain, vomiting/regurgitation. Review of Resident #4's nursing notes showed no documentation that Resident #4's family was notified of a change in condition that occurred on 2/26/2026. During an interview on 4/7/2026 at 1:16 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #4's name] daughter was in the building the day the pulmonary consult and chest x-ray were ordered. I spoke with her, and she was aware. Review of Resident #4's health status note dated 3/3/2026 read, pt [patient] experiencing flu like symptoms. MD informed and order tamiflu bid [twice daily] x5 [for 5] days. Review of Resident #4's nursing notes showed no documentation that Resident #4's family was notified of a change in condition that occurred on 3/3/2026. During an interview on 4/8/2026 at 10:08 AM, Staff D, RN, stated, I reached out to the family, but I don't believe I got an answer on that day and I don't know if they called back. If family doesn't answer the phone, we try to let the next nurse know to call. Normally I document when I try to call family, but that day was busy and I forgot. During an interview on 4/8/2026 at 9:05 AM, the DON reviewed the documentation and stated, I do not see any documentation that the resident's family was notified of the resident's changes in condition. I would like for the nurses to put a note in when they notify a resident's family about a change. 6) Review of Resident #44's physician order dated 3/28/2025 read, Novolog Solution 100 unit/ml (Insulin Aspart), Inject as per sliding scale: if 0-200= 0u; 201-250= 2u; 251-300= 4u; 301-350= 6u; 351-400= 8u; 401+ = 10u Over 400, administer 10 units and notify MD, subcutaneously two times a day for DM II. Review of Resident #44's MAR for March 2026 for administration of Novolog Solution two times a day documented a BS of 402 on 3/3/2026 at 8:00 PM, a blood sugar of 421 on 3/9/2026 at 8:00 PM, a BS of 410 on 3/13/2026 at 8:00 PM, a BS of 403 on 3/17/2026 at 8:00 PM, a BS of 535 on 3/19/2026 at 8:00 PM, and a BS of 562 on 3/21/2026 at 8:00 PM. Review of Resident #44's nursing progress notes for March 2026 showed no documentation of physician notification for blood glucose over 400. Review of Resident #44's physician order dated 11/15/2025 read, Aspirin Tablet Chewable 81 MG, Give 1 tablet by mouth one time a day for preventative. Review of Resident #44's MAR for March 2026 for administration of Aspirin showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/26/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Aspirin showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Atorvastatin Calcium Oral Tablet 80 MG (Atorvastatin Calcium), Give 1 tablet by mouth at bedtime for HLD [Hyperlipidemia]. Review of Resident #44's MAR for March 2026 for administration of Atorvastatin showed code 2 documented at 6:00 PM on 3/2/2026, 3/3/2026, 3/9/2026 through 3/12/2026, 3/16/2026 through 3/22/2026, 3/24/2026, 3/25/2026, 3/27/2026, 3/28/2026, 3/30/2026, and 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Atorvastatin showed code 2 documented at 6:00 PM on 4/1/2026 through 4/4/2026, 4/6/2026, and on 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Carvedilol Tablet 25 MG, Give 0.5 tablet by mouth two times a day for HTN, Hold if SBP [Systolic Blood Pressure] <100 or HR [Heart Rate]<60. Review of Resident #44's MAR for March 2026 for administration of Carvedilol showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026 through 3/31/2026; and at 6:00 PM on 3/2/2026, 3/3/2026, 3/9/2026 through 3/12/2026, 3/16/2026 through 3/22/2026, 3/24/2026, 3/25/2026, 3/27/2026, 3/28/2026, 3/30/2026, and 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Carvedilol showed code 2 documented at 6:00 AM on 4/1/2026 thorough 4/7/2026; and at 6:00 PM on 4/1/2026 through 4/4/2026, and on 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Clopidogrel Bisulfate Oral Tablet 75 MG (Clopidogrel Bisulfate), Give 1 tablet by mouth in the morning for CVA. Review of Resident #44's MAR for March 2026 for administration of Clopidogrel Bisulfate showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Clopidogrel Bisulfate showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Colace Capsule 100 MG (Docusate Sodium), Give 1 capsule by mouth two times a day for constipation. Review of Resident #44's MAR for March 2026 for administration of Colace showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, 3/16/2026, and 3/18/2026 through 3/31/2026; and at 6:00 PM on 3/2/2026, 3/3/2026, 3/9/2026 through 3/12/2026, 3/16/2026 through 3/22/2026, 3/24/2026, 3/25/2026, 3/27/2026, 3/28/2026, 3/30/2026, and 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Colace showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026; and at 6:00 PM on 4/1/2026 through 4/4/2026, 4/6/2026, and 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Farxiga Oral Tablet 10 MG (Dapagliflozin Propanediol), Give 1 tablet by mouth one time a day for type 2 dm. Review of Resident #44's MAR for March 2026 for administration of Farxiga showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026, and 3/18/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Farxiga showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44' physician order dated 11/15/2025 read, Furosemide Tablet 20 MG, Give 1 tablet by mouth in the morning for HTN [Hypertension]. Review of Resident #44's MAR for March 2026 for administration of Furosemide showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Furosemide showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Januvia Tablet 50 MG [milligram] (Sitagliptin Phosphate), Give 1 tablet by mouth one time a day for dm. Review of Resident #44's MAR for March 2026 for administration of Januvia showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Januvia showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Lisinopril Oral Tablet 20 MG (Lisinopril), Give 1 tablet by mouth in the morning for HTN. Review of Resident #44's MAR for March 2026 for administration of Lisinopril showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Lisinopril showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Protein Oral Liquid (Protein), Give 30 ml by mouth in the morning for nutritional supplement. Review of Resident #44's MAR for March 2026 for administration of Protein Oral Liquid showed code 2 documented at 6:00 AM on 3/1/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Protein Oral Liquid showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's physician order dated 11/15/2025 read, Prozac Oral Capsule 10 MG (Fluoxetine HCl [hydrochloride]), Give 1 capsule by mouth in the morning for depression. Review of Resident #44's MAR for March 2026 for administration of Prozac showed code 2 documented at 6:00 AM on 3/1/2026, 3/3/2026 through 3/14/2026, and 3/16/2026 through 3/31/2026. Review of Resident #44's MAR for April 2026 for administration of Prozac showed code 2 documented at 6:00 AM on 4/1/2026 through 4/7/2026. Review of Resident #44's nursing progress notes dated 3/19/2026 read, Resident refused 1800 [6:00 PM] medications. Review of Resident #44's nursing progress notes dated 3/30/2026 read, Patient refused all meds. Vitals were outside parameters for insulin. Review of Resident #44's nursing progress notes dated 4/6/2026 read, Resident refused all 0600 [6:00 AM] meds except for insulin. Vitals were outside of parameters for insulin. Review of Resident #44's nursing progress notes dated 4/7/2026 read, Resident refused all meds. BG [Blood Glucose] was below the parameters for coverage. Review of Resident #44's nursing progress notes from March 1, 2026 through April 7, 2026 showed no physician notification of resident refusal to take prescribed medications. During an interview on 4/8/2026 at 9:40 AM, Staff B, RN Unit Manager stated, We do not wake them up to give them medications; we would go back later. If refusal is marked off on the MAR, it would have a progress note attached saying the doctor was called. For blood sugars over 400, we just acknowledge the order and that is all the documentation that needs to be done. I would assume that the nurse should make a note saying the doctor was notified. During an interview on 4/8/2026 at 11:50 AM, the DON stated, Nurses routinely contact doctors through the secure system. The communication should be documented about who they texted or spoke to. During an interview on 4/8/2026 at 12:25 PM, Resident #44's Physician stated, I get notified of high blood sugars and resident medication refusals by the messaging system myself and my nurse practitioner. Unfortunately, [Resident #44's name] has been noncompliant for years not just months. One reason she ended up with another stroke a year ago was because she was not taking her blood pressure meds. 7) Review of Resident #3's physician order dated 2/17/2026 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), Inject 12 unit subcutaneously in the morning for DM2. The order was discontinued on 3/9/2026. Review of Resident #3's MAR for March 2026 for administration of Insulin Glargine documented code 2 on 3/3/2026 and code 9 (see nurses notes) on 3/4/2026. Review of Resident #3's physician order dated 3/10/2026 read, Insulin Glargine Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Glargine), Inject 15 unit subcutaneously in the morning for DM2. Review of Resident #3's MAR for March 2026 for administration of Insulin Glargine documented Code 9 (see nurses notes) on 3/28/2026, and documented Code 2 on 3/31/2026. Review of Resident #3's MAR for April 2026 administration of Insulin Glargine documented code 9 on 4/2/2026, 4/3/2026 and 4/4/2026, and documented code 2 on 4/5/2026. Review of Resident #3's physician order dated 2/16/2026 read, Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml (Insulin Aspart), Inject as per sliding scale: if 151-200= 1 unit; 201-250= 2 unit; 251-300= 3 unit; 301-350= 4 unit; 351-400= 5 unit; 401+ = 6 units, Notify MD, subcutaneously before meals and at bedtime for DM2. Review of Resident #3's MAR for March 2026 for administration of Insulin Aspart per sliding scale showed no blood sugar documented on 3/4/2026 and code 9 documented at 6:30 AM. Review of Resident #3's physician order dated 2/16/2026 read, Insulin Aspart Subcutaneous Solution Pen-Injector 100 unit/ml (Insulin Aspart), Inject 6 units subcutaneously before meals for DM2. Review of Resident #3's MAR for March 2026 for administration of Insulin Aspart 6 units documented code 9 on 3/4/2026, 3/26/2026, and 3/27/2026; and documented Code 2 on 3/8/2026, and 3/31/2026. Review of Resident #3's MAR for April 2026 for administration of Insulin Aspart 6 units documented code 9 at 6:30 AM on 4/2/2026, 4/3/2026, and 4/4/2026, and documented code 2 on 4/5/2026. Review of Resident #3's nursing progress notes for March 2026 showed no documentation of physician notification of medication refusal. Review of Resident #3's nursing progress notes for April 2026 showed no documentation of physician notification of medication refusal.During an interview on 4/7/2026 at 8:40 AM, Staff A, LPN, stated, I document blood sugar if they let me do blood sugar. If insulin is refused, I put in a progress note and notify MD and reeducate on importance of insulin. During an interview on 4/8/2026 at 12:30 PM, Resident #3's Physician stated, [Resident #3's name] has always been reluctant to take his insulin because he is noncompliant with his diabetes. They notify myself or my nurse practitioner of refusals.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene while providing direct care to the residents and failed to ensure staff used proper PPE (Personal Protective Equipment) while providing high-contact care to the residents on enhanced barrier precautions to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 11/4/2024 at 1:05 PM, Staff D, Licensed Practical Nurse (LPN), returned to the medication cart. Without performing hand hygiene, Staff D removed medication for Resident #36 and wheeled Resident #36 to her room. Staff D administered Resident #36's medications in her room and wheeled her back to the hall without performing hand hygiene. Staff D returned to the medication cart, and without performing hand hygiene, walked away and went to grab a box of cigarettes for Resident #36. Staff D returned to the medication cart, and without performing hand hygiene, wheeled Resident #44 back to her room. During an observation on 11/5/2024 at 9:05 AM, Staff D, LPN, entered Resident #15's room and administered the medications. Staff D exited the room, and without performing hand hygiene, started to document on the computer. Without performing hand hygiene, Staff D began to pour medications for Resident #5 and administered the medication in the resident's room. Staff D exited the room without performing hand hygiene. Staff D heard Resident #5 coughing. Staff D entered the resident room to check if he was ok. Staff D proceeded to put medication away in the medication cart without performing hand hygiene. During an interview on 11/6/2024 at 10:10 AM, the Infection Preventionist stated, Staff should be performing hand hygiene in between each resident. Washing your hand to prevent infection is something everyone can control. During an interview on 11/7/2024 at 8:44 AM, Staff D, LPN, stated, I have been a nurse for seven years. I know better than that. You should do hand hygiene in between any interaction you have with residents. During an interview on 11/7/2024 at 11:40 AM, the Director of Nursing (DON) stated, Staff should be preforming hand hygiene in between each resident contact. 49656 2) During an observation on 11/5/2024 at 1:15 PM, Staff D, LPN, started preparing medications for Resident #21 without performing hand hygiene. Staff D locked the medication cart, entered Resident #21's room and administered the medications without performing hand hygiene. After taking the medication, the resident knocked over her water container onto the floor. Staff D exited the resident's room without performing hand hygiene, went to get a towel to clean up the water, and returned to clean up water off of the floor. At 1:21 PM, Staff D exited Resident #21's room without performing hand hygiene and returned to the medication cart. Staff D unlocked the cart and prepared medications for Resident #44 without performing hand hygiene. Staff D locked the medication cart, entered Resident #44's room and administered the medications without performing hand hygiene. At 1:24 PM, Staff D exited Resident #44's room, returned to the medication cart and began preparing medications for Resident #37 without performing hand hygiene. Staff D entered Resident #37's room and administered the medications. Without performing hand hygiene, Staff D returned to the medication cart. During an interview on 11/5/2024 at 1:56 PM, the Assistant Director of Nursing stated, I talked to [Staff D's name] about not washing his hands between residents and he said that he did hand sanitizer between residents. I then went and reviewed the video tape which showed that he did not use the hand sanitizer and did not wash his hands. During an interview on 11/5/2024 at 2:27 PM, Staff D, LPN, stated, As soon as you left, I realized that I had not done hand hygiene/washed hands between residents. I know better. I have been taught that since the beginning. Review of the facility policy and procedure titled Administering Medications with the last review date of 7/23/2024 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 22. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 49289 3) During an observation on 11/4/2024 at 12:52 PM, Staff A, Certified Nursing Assistant (CNA), entered Resident #77's room, and without performing hand hygiene, donned gloves and carried a gait belt [a transfer belt worn around the resident's waist that staff hold onto to help transfer a resident with balance issues] to Resident #77's bedside to assist the resident in transferring from his wheelchair to his bed. Before transferring Resident #77, Staff A doffed her gloves, and without performing hand hygiene, proceeded down the hallway to the equipment storage area near the nursing station outside 200 Hall. Staff A set the gait belt down, and without performing hand hygiene, grabbed the sit-to-stand lift [an electric standing and raising piece of equipment used to enable residents to be raised up from a seated position and transferred to a bed, chair, toilet, or wheelchair] and proceeded back to Resident #77's room. Without performing hand hygiene, Staff A donned gloves and assisted the resident to transfer from his wheelchair to his bed using the sit-to-stand lift. At 12:58 PM, Staff A doffed her gloves, and without performing hand hygiene, exited Resident #77's room and brought the sit/stand lift back to the equipment storage area. Staff A then proceeded down the hall, and without performing hand hygiene, entered Resident 40's room. Staff A passed Resident #40 their personal care items on their bedside stand without performing hand hygiene. During an interview on 11/6/2024 at 9:27 AM, the Assistant Director of Nursing (ADON) stated, The expectation for staff is that they do hand hygiene every time you [Staff] go in a room and do anything with a resident, including, anything where you come in contact with the resident or surfaces. Gloves do not replace hand hygiene. During a telephone interview on 11/6/2024 at 11:52 AM, Staff A, CNA, stated, I should have used the sanitizer for my hands before I donned my gloves when I helped with [Resident #77's name]. Before I entered [Resident #40's name] room, I should have used the hand sanitizer or wash my hands. 4) Review of Resident #34's medical record showed the resident was admitted on [DATE] with diagnoses including sepsis due to Escherichia coli (E. coli), stage 2 pressure ulcer of sacral region, urinary tract infection, retention of urine, malignant neoplasm of prostate, type 2 diabetes mellitus, acute pyelonephritis, hydronephrosis, obstructive and reflux uropathy, and bacteremia. Review of Resident #34 physician order dated 10/20/2024 read, Enhanced Barrier Precautions: PPE required for high resident care activities. Indication: wounds, indwelling medical device, infection and/or MDRO [Multi-Drug Resistant Organism] status. During an observation on 11/5/2024 at 8:44 AM, there was an Enhanced Barrier Precautions (EBP) sign attached to Resident #34's door facing the hallway. Staff B, CNA, exited Resident #34's room into the hallway and spoke to Staff C, CNA. Without performing hand hygiene, Staff B and Staff C entered Resident #34's room and donned gloves. Without wearing a gown, Staff B proceeded to the right side of Resident #34's bed and Staff C proceeded to the left side of the resident's bed. Resident #34's indwelling urinary catheter was intact and the tubing was draped across the bed and down the left side of the bed with the catheter bag hanging directly to the left of where Staff C was standing to reposition Resident #34 in bed. While standing on each side of Resident 34's bed, Staff B and Staff C gathered up the linen under Resident #34's back and legs. While standing on each side of Resident #34, Staff B and Staff C had their lower bodies pressed against the resident's linen covered mattress, and without wearing gowns, pulled Resident #34's body toward the head of the bed. After repositioning Resident #34 in bed, Staff B and Staff C readjusted the resident's top blankets to cover the resident, doffed their gloves, and exited Resident #34's room without performing hand hygiene. During an interview on 11/6/2024 at 9:27 AM, the Assistant Director of Nursing (ADON) stated, The expectation for staff is that they do hand hygiene every time you [Staff] go in a room and do anything with a resident, including, anything where you come in contact with the resident or surfaces. When they [residents] are on EBP, the process is you should gown and glove. Gloves do not replace hand hygiene. During an interview on 11/6/2024 at 10:08 AM, Staff B, CNA, stated, I should have been wearing a gown and gloves when lifting [Resident #34's name] on EBP up in bed and when providing direct care. I was not wearing a gown. I washed my hands in the hallway before I picked up [Resident #34's name] tray and entered the room. I performed hand hygiene in the hallway before I entered the room the first time with the tray. During an interview on 11/6/2024 at 10:33 AM, Staff C, CNA, I wasn't wearing a gown when we pulled [Resident #34's name] up in bed. I was told we didn't have to if we were just pulling them up in bed when they are on EBP. I washed my hands before I went in the room. During an interview on 11/7/2024 at 11:45 AM, the Director of Nursing stated, The staff should wear PPE only when providing prolonged direct care, such as transfers that are max assist and when changing linens. The residents already feel some type of way and we do not want to make them feel they are contaminated. I would not expect them [the staff] to wear PPE for meal delivery, adjusting a resident in their bed, covering them up with linen, or giving them something. If so, they would be contact precautions. Review of the signage posted on Resident #34's door read, Enhanced Barrier Precautions: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device Care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 7/23/2024 read, Policy Statement: Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EPBs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as apposed to entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing, b. bathing/showering, c. transferring, d. providing hygiene, e. changing linens, f. changing briefs or assisting with toileting, g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.), h. wound care (any skin opening requiring a dressing) . 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 48708 5) During an observation on 11/4/2024 at 1:47 PM, Staff E, CNA, exited Resident #31's room after completing incontinence care with a pair of used gloves in their hand. Staff E proceeded down the hallway and threw the gloves in the trash bin at the medication cart. Without performing hand hygiene, Staff E proceeded down the hallway to Resident #233's room, and entered Resident #233's room to assist the resident without performing hand hygiene. During a telephonic interview on 11/7/2024 at 11:00 AM, Staff E, CNA, stated, I washed my hands before I left the room, and then realized I had not thrown away the gloves, so I carried the gloves down to the nurses cart and threw them away there. During an interview on 11/7/2024 at 11:45 AM, the Director of Nursing stated she expected staff to sanitize their hands before and after direct care. Review of the facility policy and procedure titled Handwashing/Hand Hygiene with the last review date of 7/23/2024 read, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Policy Interpretation and Implementation . 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors . Indications for hand hygiene: 1. Hand hygiene is indicated: a. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device) . c. after touching a resident; d. after touching the resident's environment . f. immediately after glove removal . 5. The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview, and record review, the facility failed to ensure residents received nutritional supplements for 1 (Resident #62) of 2 residents reviewed for nutrition. Findings include: During an observation on 11/5/2024 at 12:12 PM, Resident #62 was eating lunch in the dining room. Resident #62's meal tray had carrots, bowtie pasta, beef tips, cake, and coffee. There was no nutritional shake on the meal tray. After a few minutes, Resident #62 stood up and stated she could not eat any more and left to her room. Resident #62 consumed approximately 25% of her meal. During an observation on 11/6/2024 at 8:20 AM, Resident #62 was eating breakfast in the dining room. Resident #62's meal tray had coffee, toast, bacon, scrambled eggs, and grits. There was no nutritional shake on the tray. During an observation on 11/6/2024 at 12:30 PM, Resident #62 was eating lunch in her room accompanied by her daughter. Resident #62's meal tray had two pieces of fried chicken, mashed potatoes, green beans, brownie, coffee, and tea. There was no nutritional shake on the meal tray. During an interview on 11/6/2024 at 12:31 PM, Staff G, Certified Nursing Assistant (CNA), stated, I delivered [Resident #62's name] meal tray to her room. She is eating with her daughter. The tray had fried chicken, mashed potatoes green beans, brownie, coffee and tea. Review of Resident #62's physician order dated 10/24/2024 read, Health Shake with meals-Dietary to provide. Review of Resident #62's Weights and Vitals Summary showed the resident weighed 117.6 lbs (pounds) on 8/28/2024, and 116.8 lbs on 9/28/2024, which is a -0.68% loss. During an interview on 11/6/2024 at 1:16 PM, the Director of Nursing stated that the nutritional shakes should come from the kitchen on the meal tray. During an interview on 11/6/2024 at 1:31 PM, the Registered Dietitian stated, She [Resident #62] does not have a big appetite. We try and give her Med Pass and health shakes. Med Pass is three times a day and the nurses give her that and the shake comes with meals and CNAs give her that. During an interview on 11/7/2024 at 10:20 AM, Staff F, CNA, stated, The kitchen brings the health shakes on the tray. Sometimes we will have some in the refrigerator, but we did not have any. [Resident #62's name] did not get health shake on her meal tray. During an interview on 11/7/2024 at 10:20 AM, Staff G, CNA, stated, The kitchen sends the nutritional shake with the tray. [Resident #62's name] did not have her nutritional shake on her meal tray. During an interview on 11/7/2024 at 10:22 AM, the Dietary Manager stated, I have a list in the kitchen with the residents' names who have an order for nutritional shakes. The kitchen aide did not check the list, and she missed it. Review of the facility policy and procedure titled Food and Nutrition Services with the last review date of 7/23/2024 read, Policy Statement: Each resident is provided with a nourishing, palatable, well-balance diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on observation, interview, and record review, the facility failed to ensure medical records were accurate for 1 (Resident #69) of 2 residents reviewed for oxygen therapy. Findings include: During an observation on 11/4/2024 at 9:53 AM, Resident #69 was lying in bed with her eyes closed, receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 11/5/2024 at 9:10 AM, Resident #69 was lying in bed, receiving oxygen via nasal cannula. Review of Resident #69's physician order dated 8/31/2024 read, Titrate oxygen for O2 [NAME] [oxygen saturations] below 90% starting at 2 L/min [liters per minute] and go up 1 L/min until O2 above 90%. Ok to use a mask or non-rebreather mask once at 10 L/min. Notify MD [medical doctor] when 02 Sats below 90%. As needed for 02 SAT below 90%. Review of Resident #69's Treatment Administration Record for November 2024 showed no documentation for oxygen use on 11/4/2024 and 11/5/2024. During an interview on 11/6/2024 at 10:55 AM, the Director of Nursing stated, [Resident #69's name] orders should have been changed to continuous oxygen. The staff are expected to document based on the orders and the services the resident is receiving. During an interview on 11/7/2024 at 11:26 AM, Staff D, Licensed Practical Nurse (LPN), stated, I did not know she had a prn [as needed] order for oxygen. I might have overlooked that. Normally you go into the system and click off if the resident is using the oxygen. Review of the facility policy and procedure titled Charting and Documentation with the last review date of 7/23/2024 read, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation . 2.The following information is to be documented in the resident medical record . c. Treatment or services performed.

Based on record review and interview, the facility failed to ensure resident records were accurate for 1 of 7 residents reviewed for advanced directives, Resident #67, and 1 of 2 residents reviewed for nutrition, Resident #19. Finding include: 1. Review of Resident #67's records revealed Resident #175's DNR (Do not Resuscitate) form uploaded into the electronic medical record. Review of Resident #67's care plan initiated on 4/25/2023 reads, [Resident #67] has advanced directives: Full Code, HCS. Review of the physician order dated 4/22/2023 for Resident #67 reads, Full Code. During an interview on 7/17/2023 at 1:18 PM, Resident #67 stated, I want to be resuscitated. During an interview on 7/17/2023 at 1:28 PM, the Director of Nursing stated, Mr. [Resident #67's name] is a full code, and that DNR was incorrectly uploaded into his medical record. 46523 2. Review of Resident #19's Weights and Vitals Summary read, 06/14/2023, 160.8 Lbs [pounds] (Wheelchair) . 05/17/2023, 161.8 Lbs (Standing) . 04/2/2023, 169.6 Lbs (Wheelchair) . 02/15/2023, 170.2 Lbs (Wheelchair). Review of Registered Dietician's noted dated 6/29/2023 at 11:14 AM for Resident #19 reads, Rt's [Resident's] appetite and intake is fair is fair but fluid intake is poor around 500 ml [milliliters] per day. Weighs 161.8 lbs on 5/17/23 and lost about 8.4 lbs (5%) in 3 months. Wt [weight] loss may be due to lasix use and fair appetite. Being on remeron may also help improve her appetite and weight. Continues on NAS [No Salt Added], NCS [No Concentrated Sweets] diet with 90 ml SF medpass tid [three times a day] to help improve weight, total proteins and maintain albumin levels. On MVM [multivitamin/mineral] supplement to help with anemia. Plan: Continue on current diet and medpass and MVM supplements. Recommend to have TSH [Thyroid Stimulating Hormone] levels done due to being on Synthroid. Continue to monitor weights and labs and adjust diet and supplements accordingly. Review of Registered Dietician's note dated 6/29/2023 at 11:48 AM for Resident #19 reads, Rt's wt is at 131.6 lbs. on 6/8/223. lost about 14.6 lbs (10%) in 3 months. Appetite and intake is fairly good and ate 100% at lunch today. Continues on 90 ml medpass tid and 30 ml liquid protein qd [once a day] to help maintain weight and albumin levels. Labs indicate anemia, low albumin, and high glucose & BUN [Blood Urea Nitrogen]. Plan: Continue on current diet and supplements. Encourage fluids for hydration. Monitor weights and adjust diet as needed. During an interview on 7/19/2023 at 1:55 PM, the Registered Dietician stated, I was working in the facility and the internet was not great. I was copying and pasting quickly and in a hurry to lock in the notes before it would delete. The correct one is the 161.8 pounds. The other one was for another resident whom also was on the weight lost list. During an interview on 7/19/2023 at 2:15 PM, the Administrator stated, I expect documentation to be accurate and staff revise their work. Review of the policy and procedures titled Charting Errors and/or Omissions last reviewed on 7/14/2023 reads, Policy Statement: Accurate medical records shall be maintained by this facility.

Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 2 residents sampled for nutrition, Resident #19. Findings include: During an observation on 7/17/2023 at 12:33 PM, Resident #19 was eating lunch independently in her room, with the meal ticket reading NAS (no salt added). During an observation on 7/18/2023 at 8:41 AM, Resident #19 was eating breakfast independently in her room, with the meal ticket reading NAS. Review of Resident #19's dietary order dated 11/22/2022 reads, NAS (No Added Salt) diet, Regular texture, Regular consistency. Review of Resident #19's Annual Minimum Data Set (MDS) dated [DATE] revealed no information under Section K Swallowing/Nutritional Status. K0510 Nutritional Approaches . D. Therapeutic diet (e.g. low salt, diabetic, low cholesterol). Review of Resident #19's Medicare-5 day MDS dated [DATE] revealed no information under Section K Swallowing/Nutritional Status. K0510 Nutritional Approaches . D. Therapeutic diet (e.g. low salt, diabetic, low cholesterol). During an interview on 7/19/2023 at 10:59 AM, the MDS Coordinator stated, [Resident #19's name] was getting a NAS diet since 11/22/2022. I think the staff meant to click the box on top of the not assessed. I am not sure why he did that. The therapeutic diet was not addressed on the MDS dated [DATE] also. Review of the policy and procedure titled MDS Assessment Coordinator last reviewed on 7/14/2023, reads, Policy Statement: A registered nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). Policy Interpretation and Implementation . 3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a. dating and signing the assessment (MDS).

Based on record review and interview, the facility failed to ensure medication administration records were complete and accurately documented for 2 of 3 of sampled residents, Resident #1 and Resident #6. Findings include: Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 12 hours for anxiety, with start date of 1/29/2021; on 6/8/2022 at 6:00 PM, on 6/22/2022 at 6:00 PM, and on 6/28/2022 at 12:00 AM and 6:00 AM, Acetaminophen Extra Strength Tablet 500 milligrams (Acetaminophen), give 2 tablet by mouth every 6 hours for pain, with start date of 10/3/2020; on 6/8/2022 at 6:00 PM, on 6/22/2022 at 6:00 PM, and on 6/28/2022 at 12:00 AM and 6:00 AM, [MEDICATION(S)] HCI Tablet 15 milligrams, give 1 tablet by mouth every 6 hours for pain, with start date of 10/3/2020; on 6/8/2022 at 6:00 PM, on 6/22/2022 at 6:00 PM, and on 6/28/2022 at 12:00 AM and 6:00 AM, [MEDICATION(S)] HCI Tablet 2 milligrams, give 2 milligrams by mouth every 6 hours for muscle spasms, with start date of 1/27/2022. Review of Resident #6's MAR for the period 6/1/2022 through 6/30/2022 revealed no documentation of medication administration on the following dates for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 6:00 PM, on 6/3/2022 at 10:00 AM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, and on 6/28/2022 at 5:00 PM, Cranberry Tablet 450 milligrams, give 2 tablet by mouth two times a day for Urinary Tract Infection ([CONDITION(S)]) prevention, with start date of 1/21/2021; on 6/1/2022 at 6:00 PM, on 6/3/2022 at 10:00 AM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, and on 6/28/2022 at 5:00 PM, Iron Supplement Tablet ([MEDICATION(S)] Sulfate), give 325 milligrams by mouth two times a day for low H&H (Hemoglobin and Hematocrit), with start date of 1/19/2021; on 6/1/2022 at 6:00 PM, on 6/3/2022 at 10:00 AM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, and on 6/28/2022 at 5:00 PM, [MEDICATION(S)] Tablet 25 milligrams, give 25 milligrams by mouth two times a day for elevated HR/BP (Heart Rate/ Blood Pressure) Hold medication if BP <110, apical [NAME] <60, with start date of 3/29/2021; on 6/1/2022 at 6:00 PM, on 6/3/2022 at 10:00 AM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, and on 6/28/2022 at 5:00 PM, [MEDICATION(S)] Powder ([MEDICATION(S)]), give 17 gram by mouth two times a day for Constipation Mix 17 grams with 4-6 ounces of fluid and drink twice a day, with start date of 1/19/2021; on 6/1/2022 at 6:00 PM, on 6/3/2022 at 10:00 AM and 2:00 PM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, Altamist Spray Solution 0.65% (Saline), 1 spray in each nostril three times a day for dry nares, with start date of 1/19/2021 and discontinuation date of 6/22/2022; on 6/3/2022 at 9:00 AM and 1:00 PM, [MEDICATION(S)] HCI Capsule, give 600 mg by mouth three times a day for [CONDITION(S)] related to [CONDITION(S)] of right lower limb (L03.115) for 14 days, with start date of 5/21/2022; on 6/3/2022 at 2:00 PM, [MEDICATION(S)] HCI Tablet 50 milligrams, give 2 tablets by mouth three times a day for pain management, with start date of 12/13/2021, on 6/3/2022 at 2:00 PM, Tylenol Tablet 325 milligrams (Acetaminophen), give 2 tablets by mouth three times a day for increase pain, with start date of 12/13/2021; on 6/1/2022 at 6:00 PM, on 6/3/2022 at 12:00 PM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, and on 6/28/2022 at 6:00 PM, [MEDICATION(S)] Tablet 0.5 milligram ([MEDICATION(S)]), give 1 tablet by mouth every 6 hours for anxiety Hold for sedation, with start date of 2/4/2022; on 6/1/2022 at 6:00 PM, on 6/3/2022 at 10:00 AM and 2:00 PM, on 6/8/2022 at 6:00 PM, on 6/16/2022 at 6:00 PM, and on 6/28/2022 at 5:00 PM, [MEDICATION(S)] HCI Capsule 10 milligrams, give 1 capsule by mouth four times a day for abdominal discomfort, with start date of 1/21/2021; and on 6/3/2022 at 11:00 AM, on 6/8/2022 at 4:30 PM, on 6/28/2022 at 4:30 PM, and on 6/30/2022 at 4:30 AM, [MEDICATION(S)] Solution 100 Unit/ML (Insulin [MEDICATION(S)]) inject as per sliding scale: If 0-150=0u; 151-200=2u; 201-250=4u; 251-300=6u; 301-350=8u; 351-400=10u Over 400 administer 12u and notify, subcutaneously before meals and at bedtime times for diabetes mellitus II, with start date of 3/8/2022. During an interview on 7/1/2022 at 11:58 AM, the Director of Nursing (DON) stated, I usually audit the MARs the 2nd Friday of every month or at least once a month. As per narcotic log and interview with the staff involved, medication was given. It was a documentation error. During an interview on 7/1/2022 at 12:59 PM, Staff D, Graduate Practical Nurse (GPN), stated, I administer all medications as per physician orders. I just did not document it on the MAR. Residents are very good at reminding staff about their medications. It was a mistake. Record review of policy and procedure title Documentation of Medication Administration revised in April 2007, reads, Policy Statement: The facility shall maintain a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, interview, and record review, the facility failed to ensure food service equipment were cleaned to prevent a potential cause of foodborne outbreaks. Findings: An observation during an initial walk-through of the kitchen on 2/21/2022 at 10:10 AM with the Certified Dietary Manager (CDM) showed an excessive amount of buildup of grease on 3 of 3 lights located under the hood, the inside metal frame of the hood, and on the back wall area under the hood area, and a buildup of lint/dust debris on 3 of the 3 lights. An observation of the plate warmer equipment located at the starting end of the food steam table and tray line showed a large amount of buildup of debris and dirt around the top of the plate warmer that held clean plates for service, and on the bottom shelving of the plate warmer equipment. During an interview on 2/21/2022 at 10:15 AM, the CDM confirmed the excessive buildup of grease and dust/lint debris on 3 light covers and on the stainless metal hood frame. The CDM stated that at first, he thought it was a pebbled glass cover over the lights and then realized it was buildup. The CDM stated the maintenance department did monthly cleaning and an outside contractor did the cleaning biannually. The CDM confirmed the buildup on the plate warmer top and base of the equipment. During an interview on 2/21/2022 at 11:33 AM, the Maintenance Supervisor stated, The vents are cleaned by maintenance each month and any other regular cleaning is done by the dietary staff. I have someone that cleans the filters only for the hood system and that an outside contractor does a biannual cleaning of the entire hood system. During an interview on 2/22/2022 at 10:30 AM, the Executive Director/Administrator stated, Maintenance is responsible for filter cleaning only and the CDM is responsible for maintaining and cleaning in the dietary department. Review of the kitchen cleaning schedule showed no designated assignee or assignment for cleaning the plate warmer or under the stove hood for the light covers, stainless metal frame of the hood, or the back wall area. Review of the facility policy and procedure titled Hood Suppression System revised in May 2008, reads, Policy Interpretation and Implementation: . 9. The kitchen hood shall be professionally cleaned by a qualified outside contractor biannually as well as monthly by inhouse staff. Review of the facility policy and procedure titled Sanitization revised in October 2008 reads, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 17. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards in four (4) out of five (5) medication carts and failed to ensure expired medications were not stored with active medications in one (1) out of two (2) medication storage rooms. Findings: During an observation on 10/13/2020 at 9:10 AM of Medication Cart #1 with Staff A, Licensed Practical Nurse (LPN), Resident #65 had [MEDICATION NAME] eye drops with an open date of August 28, 2020 and one open bottle of artificial tears that was not labeled with an open date. Resident #49 had a bottle of artificial tears with an open date of June 13, 2020. During an interview on 10/13/2020 at 9:25 AM with Staff A, Licensed Practical Nurse (LPN) she stated, All medications should have the date they were opened and date that they expire. All stock eye drops should have the resident's name on the bottle. I do not know when the artificial tears expire. I guess they expire by the manufacturer's date. The TB ([MEDICAL CONDITION]) syringes should be returned to the pharmacy. During an observation on 10/13/2020 at 9:20 AM of Medication Cart #2 with Staff A, LPN, Resident #70 had one open bottle of [MEDICATION NAME] eye drops with no open date or expiration date. There was one open bottle of artificial tears without a name, open date or expiration date on the box or the bottle. During an observation on 10/13/2020 at 9:23 AM of Medication Cart #3 with Staff B, LPN, Resident #29 had an opened bottle of [MEDICATION NAME] Insulin with no open date or expiration date on the bag or the bottle. Resident #3 had one open bottle of [MEDICATION NAME] Insulin with no open date or expiration date on the bag or bottle. During an observation on 10/13/2020 at 9:30 AM of Medication Cart #4 with Staff B, LPN there was one open bottle of artificial tears without a name, open date or expiration date. During an observation on 10/13/2020 at 9:45 AM of the Medication Storage room refrigerator on the 100 unit with Staff A, LPN there were two Apisol [MEDICATION NAME] syringes with an expiration date of September 9, 2020 for Residents #3 and #36. During an interview on 10/13/2020 at 9:45 AM with Staff B, LPN she stated, I should have made sure all the medications were labeled with names, dates they were opened, and dates they expire. All insulins should be dated with the day they open and when they expire. During an interview with the Administrator, she stated, All medications should be labeled per our policies and returned to Pharmacy if they are expired or destroyed per our policies. Review of [MEDICATION NAME] manufacturer's product information revealed: Storage: Discard the eye drops 4 weeks after opening. Review of www.tearfilm.org - A Patient's Guide to Artificial Tears reads: It's generally safe and effective to use these eye drops until their expiration date. However, the AAO says that if you've already opened the eye drops, they may have a much shorter shelf life, and you should throw them away three months after opening - even if it's before expiration. A review of the Storage of Medications Policy version 1.2 (H5MAPL0851) was reviewed and read: Policy Statement: The facility stores all drugs and biologicals in a safe, secure and orderly manner. 5. Discontinued outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. A review of the Labeling of Medication Containers Policy Version 1.2 (H5MAPL0455) was reviewed and read: Policy Statement: All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Policy interpretation and implementation: 3. Labels for individual resident medications include all necessary information, such as - a. The Residents name. h. The expiration date when applicable. 4. Labels for stock medications include all necessary information such as c. The expiration date when applicable. A review of the Administering Medications Policy Version 2.1 (H5MAPL0028) was reviewed and read: 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multidose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to implement the written plan of care necessary to maintain good personal hygiene for 2 of 4 residents reviewed for Activities of Daily Living (ADL), Residents #178 and #68 in a total of 36 sampled residents. Findings include: A review of the facility policy titled, Care of Fingernails/Toenails, revised February 2018, annually reviewed on 7/30/20, reads Purpose. The purpose of this procedure are (sic) to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. 1. Review of the written plan of care for Resident #178 dated 10/12/20 reads the resident requires assistance with ADL's due to weakness, decreased endurance, and decreased mobility associated with recent hospitalization for [MEDICAL CONDITION] and renal and hepatic failure and acute pancreatitis. Interventions include check nail length and trim and clean on bath day and as necessary. Resident #178 was observed on 10/13/20 at 2:50 PM. Her fingernails on both hands were observed to be long, with dark debris under the nail beds. Her fingernail tips were also observed to have a yellowish-brown discoloration. An interview on 10/13/20 at 2:50 PM with Resident #178 revealed that she had just arrived at the facility the previous Saturday. The resident confirmed that her nails were long and dirty. Resident #178 was observed on 10/14/20 at 9:00 AM lying in bed, with her feet out of the covers. Her toenails were long, some were thick. The resident fingernails on both hands were long and had black debris under the nail beds. The fingernail tips were discolored yellowish brown. During an interview on 10/14/20 at 9:00 AM with the Resident she stated she needed to get her toenails cut. An observation of Resident #178 on 10/14/20 at 4:00 PM revealed the resident's nails were still long and had dark debris underneath the nail beds of both hands. An interview was conducted with the Director of Nursing (DON) on 10/14/20 at 4:05 PM. He confirmed that the resident's nails are long and dirty and should have been cleaned by the CNA (Certified Nursing Assistant) during the shower. He stated that the nurse should have cut the nails and toenails as the resident is a diabetic. 2. An observation on 10/14/20 at 09:10 AM of Resident #68's fingernails showed they are long uncut, and the resident was unshaven. The resident's toenails were long, thick and uncut. During an interview on 10/14/20 at 9:30 AM with the resident he stated, I have an electric razor. When asked if he could shave himself with his electric razor the resident stated, I think I can. When the resident was asked about his fingernails and toenails he stated, No body cuts them. Review of Resident #68's facility medical record revealed he was admitted into the facility on [DATE]. During an interview on 10/14/2020 at 3:10 PM with Staff D, Certified Nursing Assistant (CNA) she stated, the resident has only been here on the 200 hallway for two days. I haven't given the him a shower yet. During an interview on 10/14/2020 at 3:19 PM with Staff A, Licensed Practical Nurse (LPN) she stated, Yes, the resident's fingernails and toenails are long. He has not been seen by the Podiatrist to trim his toenails, they are long and thick. A review of the resident's CNA task sheet showed the resident is to receive a shower M-W-F on 3 PM -11 PM shift. A review of the CNA skin inspection report showed the facility CNA's were cleaning the resident's fingernails. There was no documentation to show the residents fingernails had been trimmed and no documentation to show the resident had been referred to the Podiatrist regarding his toenails. Review of the care plan dated 10/06/20 read: Requires assistance with ADL's. Goals: Will have ADL needs met with staff assistance. Interventions include: No weight bearing, upper left arm, bathing/showering check nail length and trim and clean on bath day and as necessary. Report any changes to nurse.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to maintain good personal hygiene for 2 of 4 residents reviewed for Activities of Daily Living (ADL), Residents #178 and #68 in a total of 36 residents. Findings include: A review of the facility policy titled, Care of Fingernails/Toenails, revised February 2018, annually reviewed on 7/30/20, reads Purpose. The purpose of this procedure are (sic) to clean the nail bed, to keep nails trimmed, and to prevent infections. Preparation: 1. Review the residents care plan to assess for any special needs of the resident. Review of the written plan of care for Resident #178 dated 10/12/20 reads the resident requires assistance with ADL's due to weakness, decreased endurance, and decreased mobility associated with recent hospitalization for [MEDICAL CONDITION] and renal and hepatic failure and acute pancreatitis. Interventions include check nail length and trim and clean on bath day and as necessary. Resident #178 was observed on 10/13/20 at 2:50 PM. Her fingernails on both hands were observed to be long, with dark debris under the nail beds. Her fingernail tips were also observed to have a yellowish-brown discoloration. An interview on 10/13/20 at 2:50 PM with Resident #178 revealed that she had just arrived at the facility the previous Saturday. The resident confirmed that her nails were long and dirty. Resident #178 was observed on 10/14/20 at 9:00 AM lying in bed, with her feet out of the covers. Her toenails were long, some were thick. The resident fingernails on both hands were long and had black debris under the nail beds. The fingernail tips were discolored yellowish brown. During an interview on 10/14/20 at 9:00 AM with the Resident she stated she needed to get her toenails cut. An observation of Resident #178 on 10/14/20 at 4:00 PM revealed the resident's nails were still long and had dark debris underneath the nail beds of both hands. An interview was conducted with the Director of Nursing (DON) on 10/14/20 at 4:05 PM. He confirmed that the resident's nails are long and dirty and should have been cleaned by the CNA (Certified Nursing Assistant) during the shower. He stated that the nurse should have cut the nails and toenails as the resident is a diabetic. 2. An observation on 10/14/20 at 09:10 AM of Resident #68's fingernails showed they are long uncut, and the resident was unshaven. The resident's toenails were long, thick and uncut. During an interview on 10/14/20 at 9:30 AM with the resident he stated, I have an electric razor. When asked if he could shave himself with his electric razor the resident stated, I think I can. When the resident was asked about his fingernails and toenails he stated, No body cuts them. Review of Resident #68's facility medical record revealed he was admitted into the facility on [DATE]. During an interview on 10/14/2020 at 3:10 PM with Staff D, Certified Nursing Assistant (CNA) she stated, the resident has only been here on the 200 hallway for two days. I haven't given the him a shower yet. During an interview on 10/14/2020 at 3:19 PM with Staff A, Licensed Practical Nurse (LPN) she stated, Yes, the resident's fingernails and toenails are long. He has not been seen by the Podiatrist to trim his toenails, they are long and thick. A review of the resident's CNA task sheet showed the resident is to receive a shower M-W-F on 3 PM -11 PM shift. A review of the CNA skin inspection report showed the facility CNA's were cleaning the resident's fingernails. There was no documentation to show the residents fingernails had been trimmed and no documentation to show the resident had been referred to the Podiatrist regarding his toenails. Review of the care plan dated 10/06/20 read: Requires assistance with ADL's. Goals: Will have ADL needs met with staff assistance. Interventions include: No weight bearing, upper left arm, bathing/showering check nail length and trim and clean on bath day and as necessary. Report any changes to nurse.

Based on observation and interview, the facility failed to provide meals at a proper temperature that was appetizing to the resident for 4 of 17 residents, Residents #1, #32, #53 and #176, of 17 residents served on the 400 hallway. Findings: An interview was conducted with Resident #1 on 10/13/20 at 11:36 AM. She stated the food was cold by the time it gets to her. Her hallway (400 hallway) is served last. An interview was conducted with Resident #176 on 10/13/20 at 03:15 PM. He stated that the food is fine except it is cold. An interview was conducted with Resident #32 on 10/14/20 at 09:58 AM. The Resident stated his breakfast was cold. An interview was conducted with Resident #32 on 10/14/20 at 1:20 PM. He stated his lunch was cold. An interview was conducted with Resident #53 on 10/13/20 at 12:00 PM. She stated the food is okay, but it is usually cold when it is delivered. An observation of the lunch tray service on 10/13/20 revealed an insulated food cart was delivered to the 400 unit at 12:55 PM. Staff were observed to serve each meal to individual rooms. All meals were provided to the residents in Styrofoam containers that included a three partition Styrofoam container for food, Styrofoam bowls with plastic lids for desserts, and Styrofoam cups for hot/cold liquids. All meals were delivered by 1:12 PM. An observation of the breakfast tray service on 10/15/20 revealed the following: At 9:04 AM the test tray was served in the kitchen. At 9:08 AM the food cart left the kitchen. At 9:10 AM the food cart arrived on the 400 hallway. All meals were provided to the residents in Styrofoam containers that included a three partition Styrofoam container for food, Styrofoam bowls with plastic lids for desserts, and Styrofoam cups for hot/cold liquids. There were five staff members observed assisting to serve the breakfast trays. All meals were delivered by 9:22 AM. A breakfast tray was tested for temperature compliance on 10/15/20 at 9:22 AM. The following temperatures were obtained: Oatmeal 139.6 Fahrenheit, Grits 129.3 Fahrenheit, Eggs Puree 109.1 Fahrenheit, Scrambled eggs 99.1 Fahrenheit. The scrambled eggs were tasted for proper temperature by Certified Dietary Manager (CDM) and two surveyors on 10/15/20 at 9:24 AM. The CDM confirmed that the eggs were cold. He stated he can't keep the food warm in the Styrofoam containers. An interview was conducted with Resident #1 on 10/15/20 at 9:34 AM. She stated that the eggs were lukewarm. An interview was conducted with Resident #53 on 10/15/20 at 9:45 AM. She stated her breakfast was cold when she got it this morning.

Based on observation, interview and record review the facility failed to ensure that the Medication Administration Record [REDACTED]. Findings: Review of the Medication Administration Record [REDACTED]. A review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of the next day single package pack showed that the pharmacy sent a 6:00 AM dose and a 5:00 PM dose. During an interview on 10/15/2020 at 2:30 PM Staff F, Registered Nurse (RN) stated, the [MEDICATION NAME] is only being sent to the facility to administer twice a day from the pharmacy. I checked the next day delivery packs and I only see a 6:00 AM and 5:00 PM dose of the medication. The medication is to be administered before meals. The nurses could not have given the resident three doses of [MEDICATION NAME]. There are only two doses provided. They documented the administration of the medication when it was not given for the 9:00 AM dose. A review of the Pharmacy distribution log showed the pharmacy was only sending two doses of [MEDICATION NAME] for administration a day.

Based on observation, record review and interview, the facility did not provide a thorough safety program for 1 of 4 residents (#10). Findings: During an observation of Resident #10 on 5/6/19 at approximately 11:30 AM, she started sliding and leaning out of her chair. She began moving backwards and a visitor attempted to reposition her in the chair. The visitor moved the chair which increased the sliding/ leaning dangerously of the resident over the side. The Licensed Practical Nurse /Staff C, rushed over and pulled her back into the chair. The resident was observed to push herself back and forth with her feet. There was no assistive device to assist her with positioning and safety in her wheelchair. During an interview on 5/6/19 at 11:30 AM, with Certified Nursing Assistants /Staff B, she stated Resident #10 can propel herself all over the unit. Observation of the video tape of the incident on 5/6/19 at about 11:30 AM revealed Resident #10 started to slide or lean dangerously, in the chair. A visitor left her side of the table and went to aid the resident. First, she attempted to readjust the resident in her chair as well as move the chair. The visitor moved back to her side of the table and the resident began to fall over (lean heavily) again immediately. The visitor went back to the resident and started the repositioning of the resident and the chair all over again. She walked away and the resident started to fall over and the Staff C responded. Staff C did not provide any further information or initiate additional interventions for the resident. During an interview with the Administrator on 5/6/19 at approximately 12 :30 PM she provided a view of the 11:30 AM video revealing Resident #10 was leaning dangerously from the chair. It showed the visitor trying to assist the Resident on 2 separate attempts. During an interview with the Therapist on 5/7/19 at approximately 1:00 PM regarding Resident #10's dangerous leaning position in the wheelchair on 5/6/19, he stated he tried to keep from using physical restraints and yet give her the most freedom. He stated he had been reluctant to implement devices, such as lap buddies and high back chairs, to ensure she would not fall from the chair because they are physical restraints. He stated it was his understanding the use of a lap buddy or high back reclining chair could not be used because they were physical restraints and against the regulations. He said he tried numerous interventions over an extended period of time with the falls continuing. He provided no information regarding the Hospice Nurse's attempt to provide a high back chair for this resident during previous months. Review of Resident #10's Hospice Progress Notes, dated 4/24/19, written by the assigned Hospice Registered Nurse, wrote discussed high back reclining wheelchair. Facility Unit Manager declines at this time. Further, the Nurse notes, Patient is hugging pillow and leaning to left and forward in wheelchair with eyes closed. A Deliver Order Summary from the Hospice Center notes the facility received a high back reclining wheelchair for Resident #10 on 11/1/18. During an interview with the Hospice Patient Coordinator, she stated she ordered a high back reclining chair for Resident #10 last November, (YEAR) and the facility accepted it and signed for it. She stated the facility called her on Monday 5/6/19 and wanted another high back reclining chair for Resident #10 stat. She stated no one knows the whereabouts of the first chair but it was not in use for Resident #10. Review of Resident #10's record revealed a Care Plan for Falls updated most recently 4/15/19. The Plan lists 5 falls since 12/12/18 with 3 of the 5, the Resident is falling from the wheelchair. The Resident's cognitive score was 00 and not able to be tested for the Minimum Data Set 4/9/19. The same interventions were used after falls. After the 12/12/18 fall the new objective was frequent repositioning (the Resident) while she is up in her WC to help prevent leaning forward, 12/27/18- an intervention for a fall mat changed to a 4 mat to the open side of the bed, 2/22/19,1/11/17, 10/9/16, - continue interventions on at risk falls care plan, 3/16/19, 12/13/18, 9/19/17- staff educated on proper placement of safety devices, winged mattress to bed, 4/12/19- PT falls screen with no further information. The current Fall Scale dated 3/7/19 scored the Resident as 45 which is High Risk. 9/19/17, 3/8/18, 6/8/18,- anti-thrust seat cushion to wc, add pummel cushion to wc seat Continued review of Resident #10's Care Plan for Falls beginning 10/9/16 included placement of the Resident on the Falling Star Program. There was no further information, intervention listed or monitoring provided regarding the program. After the 3/16/19 fall the Rehabilitation Screen dated 3/18/19, noted Educated the staff on keeping the bed in lowest position. It noted no evaluations were indicated for the resident. There were no signed attendance sheets for the training. On 3/16/19, a Teachable Moment Form was written for keeping the bed in lowest position and fall mats. It is signed by 8 Aides and 1 Registered Nurse , none were from the 11-7 shift. An In-service report dated 3/14/19 (before the fall) with the statement body mechanics and ergonomics with transfer training listed for the contents. It stated see attached but there was no attachment and no further directives or explanations. A Rehabilitation Screen dated 4/15/19 noted no evaluations were indicated for the resident after the fall on 4/12/19. It recommends Pt is currently cared for by Hospice. Nursing staff educated on encouraging to lean back and provide activities to redirect unsafe behavior. During an interview with the Director of Nursing (DON) on 5/7/19 at approximately 8:30 AM, he stated he did not understand the facility could use assistive devices like lap buddies and high back chairs, to prevent falls even after numerous interventions over an extended period of time to prevent falling. He said he thought that constituted physical restraints. He said he thought using the lap buddy or high back chair would be considered deficient practice which could result in a citation. He stated he gave that information to the Rehabilitation Director and his staff. He provided no further information including the Hospice Nurse's attempt to provide a high back chair for this resident during previous months. During an interview on 5/7/19 at approximately 12:30 PM, the DON provided an invoice dated 5/7/19, revealing Hospice had purchased a new high back chair for the Resident after the 5/6/19 incident. A lap buddy was provided for Resident #10 for the lunch meal on 5/7/19.

Based on observation, interview and record review the facility failed to ensure there were no expired medications or biologicals, for 1 of 2 medication storage rooms and 3 of 3 medication carts. Findings: An observation on 02/26/18 at 9:28 AM of the 300 hallway medication cart revealed 1 bottle of [MEDICATION NAME] eye drops for Resident #9 showed a date opened of 12/22 discard after 60 Days, One bottle of [MEDICATION NAME] 0.4 sublingual showed a date opened of 07/01/2017 discard after 6 months. Refresh eye drops with the name Ward with no first name, patient identifier and no directions for use. One bottle of artificial tears with the name Ward on the bottle, no first name, or directions for use. One bottle of [MEDICATION NAME] 1% for resident #69 showed no date the [MEDICATION NAME] was opened. One bottle of [MEDICATION NAME] Insulin, for Resident #3 was opened 01/15 expired 02/25/18. During an interview on 02/26/2018 at 9:40 AM with the Assistant Director of Nursing (ADON), it was observed and confirmed that the medications were out of date. The ADON stated the nurses are supposed to check the expiration dates on the medications. The resident's medications are supposed to be properly labeled. An observation of the 200 medication cart showed a bottle of [MEDICATION NAME] Insulin for Resident #227 that was not refrigerated in the medication cart drawer. The label on the bottle read to keep refrigerated until opened. There was no date to indicate when the medication was placed in the drawer. One bag of three bottles of eye drops for Resident #227 showed no directions for use. During an interview on 02/26/2018 at 9:40 AM with the Assistant Director of Nursing (ADON), observed and confirmed that the medications were expired on the 200 hallway cart. The ADON stated the nurses are supposed to check the expiration dates on the medications. In the 100 hallway medication storage/clean utility room showed, three bottles of 100 milligrams (ML) normal saline expired 01/2018. During an interview on 02/26/18 at 10:00 AM with the Director of Nursing (DON) observed and confirmed the normal saline was expired as of 01/2018. On the 400 Hallway cart on 02/16/18 at 10:50 AM in the working stock narcotic drawer, one pack of 27 of the narcotic [MEDICATION NAME] for Resident #47 was expired as of 11/29/2017. During an interview on 02/16/18 at 11:00 AM, Staff (C) Registered Nurse RN, confirmed the resident's medication was expired. The RN stated the nursing staff is responsible for checking the expiration dates on medications. A review of the policy and procedure last reviewed 04/17/17 titled medication storage outdated, contaminated, or deteriorated medications are immediately removed from inventory.

Based on observation, review of the policy and Procedures, and interview, the facility failed to provide an environment to ensure the dignity for one of 25 sampled residents (Resident #226), by having signage openly visible to other residents and visitors in the resident's room. Findings: Observation was conducted on 02/26/18 at 9:50 AM that revealed 2 paper signs in resident #226's room, one posted on the wall and one on top of the dresser. The sign posted on the wall states Resident #226's cigarettes are labeled and at nurse's station. She was smoking in her room, we had to confiscate them.' The second sign was posted on the dresser that stated, resident #226's smokes are in the drawer next to the bed with her Sea Bond and scissors to trim them. Interview and observation of resident #226's room conducted on 02/27/18 at 1:45 PM with the Director of Nursing (DON), he was shown the signage on the wall and dresser. The DON stated, the family must have put those signs up in which they did not request to do so, these signs should not be here and my staff should have removed them. Interview on 02/28/18 at 3:00 PM with Resident #226, when she was asked if she cared that these signs were on her wall about her smoking in her room, and where her cigarettes are to be kept, she stated, I don't want people knowing my business. Review of the facility's current Policy and Procedures titled Quality of Life-Dignity revealed the following statement: Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room unless specifically requested by the family

Based on observation, and interview the facility failed to ensure that call bells were within reach of resident's that were capable of using them for 3 of 20 resident's on the 100 hallway. (Rooms #105-1 room [ROOM NUMBER] and room [ROOM NUMBER]-2.) Findings: An observation on 02/26/18 at 9:17 AM showed the resident in room [ROOM NUMBER]-1 call light was clipped behind his bed on the floor. The call bell was out of the reach of the resident. (See photographic evidence.) During an interview on 02/26/18 at 9:19 AM, the resident in room [ROOM NUMBER]-1 stated, he does knows how to use his call-bell. An observation on 02/2618 at 9:38 AM revealed the call bell in room [ROOM NUMBER]-2 was attached to the wall. The call bell was not within reach of the resident. During an interview on 02/26/18 at 9:44 AM, The resident in room [ROOM NUMBER]-2 stated, she knows how to use her call bell. She stated sometimes the call bell does not work and her roommate will use her call bell. An observation on 02/26/18 at 10:40 AM revealed the call light in room [ROOM NUMBER]-2, was clipped to the wall behind the resident's bed. The call bell was not within reach of the resident. During an interview on 02/27/18 at 10:50 AM, the resident in room [ROOM NUMBER]-2 stated, she knows how to use her call bell. The resident was able to demonstrate that she could use her call bell. An observation and interview were conducted with the 200 hallway Unit Manager on 02/26/18 at 10:00 AM. The unit Manager observed and confirmed the call bells were not in reach of the residents. A review of the policy and procedure last reviewed on 04/17/17 titled Call light answering/placement indicated each resident will have access to a working call light, in a readily accessible manner, in all resident rooms/bathrooms/vacant rooms.

Based on medical record review, facility documentation and interview, it was confirmed the facility staff failed to ensure an accurate assessment was conducted for 1 of 1 [MEDICAL TREATMENT] residents in the facility of 25 sampled residents, Resident #29, specific to the acquiring of weights for a resident receiving [MEDICAL TREATMENT] therapy. Findings: A review of the facility Policy and Procedure for obtaining the weights of [MEDICAL TREATMENT] residents revealed, [MEDICAL CONDITIONS] residents receiving [MEDICAL TREATMENT] services will be recorded from [MEDICAL TREATMENT] post-weight on the middle day of their [MEDICAL TREATMENT] week in the resident ' s weight record. A review of the medical record for Resident #29 revealed no indication as to how the resident's documented weights were being determined. The word manual was documented next to the weights in the computer program. Most weights recorded in the computer correlated to a day the resident received his [MEDICAL TREATMENT] treatments, but did not match the recorded [MEDICAL TREATMENT] post weight. The resident receives [MEDICAL TREATMENT] three times weekly on Monday, Wednesday and Friday. There was no indication whether the weights were being recorded from the [MEDICAL TREATMENT] center documentation, or whether the weights were being recorded by staff in the facility. An interview was conducted with the facility Director of Nursing (DON) on 2/28/2018 at approximately 11:40 AM. The weights as recorded in the computer system and those on the [MEDICAL TREATMENT] Communication Forms were compared. It was confirmed by the Director of Nursing (DON), the facility Restorative CNAs (Certified Nursing Assistants) are taking the resident's weight in the building and documenting them. The weights that failed to show consistency included: (kg = kilogram weight; # = pounds in weight): Facility 2/28/2018: 134.8# [MEDICAL CONDITION] 59.3 kg = 130.46# Facility 1/15/2018: 131.4# [MEDICAL CONDITION] 58.2 kg = 128.04# Facility 12/29/2017: 132.2# [MEDICAL CONDITION] 57.9 kg = 127.38# Facility 10/04/2017: 134.6# [MEDICAL CONDITION] 57.3 kg = 126.06# Facility 9/04/2017: 143.8# [MEDICAL CONDITION] 64.3 kg = 141.46# Facility 7/11/2018: 144.2# [MEDICAL CONDITION] 7/12/2017 63.7 = 140.14# Facility 6/28/2017: 146.0# [MEDICAL CONDITION] blank 6/30/2017 = 144.54# The interview confirmed the lack of a facility protocol being followed for obtaining accurate weights for the resident assessment and the tool utilized for obtaining the weights for Resident #29. The weight related to potential fluid gains and losses were not being evaluated accurately due to the discrepancies in the weight documentation. The facility Director of Nursing confirmed during the interview on 2/28/2018, the weights in the medical record were monthly weights, however there was no determination as to their accuracy given the conflicting data provided. The Director of Nursing also confirmed during the interview, the weights in the computerized medical record were those reviewed and utilized by the Dietitian and Food Services Director/Certified Dietary Manager for their documentation and assessment evaluation.

Based on observation, interview and record review the facility failed to develop a baseline care plan specific to a resident having a skin tear for one of 25 sampled residents. (Resident #328). Findings: Clinical record review indicated resident #328 was admitted to the facility on [DATE]. Review of the nursing assessment for the resident completed 2/15/18 indicated the resident had a skin tear to her right elbow. The care plan dated 2/20/18 did not indicate the resident had a skin tear. Nor were there nursing notes indicating a skin tear. An observation on 02/27/18 at 9:08 AM showed Resident #328 had a dressing on her right elbow. Continued observation at 2:27 PM showed the date change on the bandage was 02/25/18. A clinical record review of the physician's orders [REDACTED]. Cleanse with normal saline. Pat dry. Change every day until healed.

Based on observation, record review and interview the facility failed to provide individualized programs to 2 of 2 residents reviewed for Activities, of 10 severely cognitively impaired residents. (#43, 45) Findings: Observation/interview of Resident #43 beginning on 2/26/18 at approximately 9:20 AM, the resident was in the Secured Unit due to his lack of safety awareness. He was ambulatory, dressed and stated his desires. He was responsive to any conversation although the content of his answers were difficult to understand. He was observed sitting in the last chair next to the wall in the same chair between 9:25 AM and 10:30 AM. He was not engaged. There was one puzzle in front of him which he pushed away. He was not observed attending to it any manner. He was observed in the chair in the same position at approximately 12:15 PM, 12:30 PM, and 1:15 PM. At approximately 1:45 PM he was observed in the television area sitting in the recliner till approximately 2:30 PM. He was not engaged. The resident stated he had been in the Air Force when he was younger and had driven a truck. He stated he did not know of any activity to do. The resident has strong eye hand coordination and gross motor coordination. He attempted to talk with staff. No staff asked him what he wanted to do or provided him with alternatives or choices. Observation of Resident # 43 beginning at 7:21 AM on 2/27/18, revealed the resident was back in the same chair waiting for breakfast. He was in the same position through lunch when he turned in his tray at 12:45 PM. He moved to his bedroom window looking out in the back courtyard. He attempted to join the staff and group at 12:48 PM in the television area. The Activities Director was observed engaging the resident in conversation from 12:52 -12:53 PM. The resident sat down in the recliner at 12:55 PM and stared out the window. The Activities Director reviewed the afternoon activities of a Ring Toss and a group activity with the rest of the facility later in the afternoon. No staff asked him what he wanted to do or provided him with alternatives or choices. During an interview with the Certified Nursing Assistant A on 2/27/18 at approximately 11:00 AM, she confirmed there was an Activity Calendar on the wall for the Secured Unit. She confirmed the residents are at different performance levels which make group activities difficult. There was no individualized schedule of activities. There was no information on 1 :1 activities. There were no alternative activities. Observation after lunch on 2/27/18 at 1:10 PM revealed a visit from a Pet until 1:17 PM. Resident # 43 did not engage. The Activities Director attempted to engage the residents in Ring Toss while the Aides were on break from 1:10 PM till 1:18 PM. Resident # 43 was not engaged. When the Aides reentered the Unit they tried to engage the resident in Ring Toss but he stood up and walked away. No other options or alternatives were offered. No further engagement was observed through 2:00 PM. Review of the Activities Calendar for the Secured Unit for 2/26/18 revealed Ring Toss in the morning and Ball Toss and Chair Exercises in the afternoon. On 2/27/18, Nail Spa and Ring Toss were in the morning with Cowboy Band and Basketball in the afternoon. The band was large group for the facility. Review of the Activity Notes revealed the most recent dated 11/14/17 in which the Director writes enjoying time in the common area, declines most group activities, will join in ball toss, balloon volley, and artwork. Activity staff will continue to invite and encourage. The Assessment was a Quarterly Participation Review most recently dated 11/14/17. It notes the goals have been met and the approaches have been effective. The Care Plan revised 10/26/16 states encourage resident and family members, needs escort to functions, remind resident he may leave activities at any time. No further options , preferences, or directives for approach for the severely cognitively impaired resident to join activities. Review of the Minimum (MDS) data set [DATE], revealed a cognition level of Moderately Impaired . There was no preference assessment. There was no monitoring/documenting of any activities of which he actually engaged. 2. ) Observation of Resident # 45 beginning on 2/26/18 between 9:05 AM-11:00 AM revealed he was in the secured unit. He was self propelling around the enclosed unit. The staff called his name and told him to come out of another Resident's room. Sometimes he came out of the room and sometimes he did not. He was self propelling through the unit, in and out of other resident ' s rooms on a continuous basis. After he was redirected out of a room, he re-entered the rooms within minutes. Observation of the window in his room [ROOM NUMBER] C, revealed blinds which were bent, broken and no longer providing any privacy from the courtyard. Further observation of the windows in Rooms 101 A & B revealed those blinds were broken in the same manner, also. The resident did not participate in any activities. He stopped propelling his wheelchair for a few minutes, attempting to elope, out the door. Observation during the Lunch meal on 2/26/18 at approximately 12:00 PM, revealed Resident # 45 was continuing to self propel in the wheelchair. He rode up to the table and grabbed a brownie from another resident and ate part of it, before returning it to the cognitively impaired resident and leaving. Observation of Resident # 45 on 2/26/18 between 12:40 PM -12:49 PM revealed the assigned floor Nurse took him outside to the courtyard. He was sitting quietly outside, looking around at the garden area. He was not observed to be engaged in any activity from 12:49 PM-2:30 PM. Observation of Resident #45 on 2/27/18 revealed the following: 10:19 AM propels into the ladies room [ROOM NUMBER] B while they are providing care. 10:22 AM tried to go into 101 B and staff redirected. 10:23 AM attempted to elope from the room - staff told him no and he yelled he wanted to go. 10:24 AM attempting to exit the door 10:25 AM turning out light by the door and moving door handles and pushing the door. 10:28 AM tried to push open the kitchen door 10:29 AM turned off the lights again 10:32 AM in ladies room [ROOM NUMBER] B again Nurse redirected. 10:34 AM in 101 B moving toward the blinds again. 2 of 2 aides in 101 D rendering care to another resident 10:35 AM in 101 B again going in/out 10:36 AM in 101 B again - Aide redirecting. he went straight to main door, reaching for light and security code box. 10:37 AM Aide says No. He goes back to 101 B. 10:40 AM in /out of all resident rooms 10:43 AM in 101 B tried to open soiled linen door staff calls him away - only activity offered was coloring the paper. He said no. 10:44 AM in 101 B 10:46 AM in 101 B when aide retrieved him - she shut the door finally. He opened door and wheeled in. Aide called him out. 10:52 AM propelling through the room attempting to go in all resident rooms. 10:54 AM in 101 B At 1:00 PM the Activities Director enters the secured unit and attempts to engage Resident # 45 in the Ring Toss but he declines after 1 minute. She stays until 1:17 PM then leaves for the large group music activity for the facility. Resident # 45 did not participate. He was not engaged through 2:00 PM. Review of the Resident # 45 ' s Activity Care Plan revealed it was last revised on 8/9/17. It states he prefers to go outside. For the month of 02/18 his Activity tracking sheet reflects no outside visits until the survey started on 2/26/18. It states he prefers to socialize with peers. It directs to remind him he may leave activities at any time . There are no directives or measurable objectives for any individual tasks, directives for approaching him as he is severely cognitively impaired or directives for his agitation. His Cognitive score is a 7 on the Minimum (MDS) data set [DATE]. His Psychiatric Consultation report dated 1/6/18 stated he was agitated with poor insight . Review of the Participation Log for 12/17 reveals 5 days with checks for any task. There were 2 days for 01/18 and almost every day for 02/18. A check was given for the Ring Toss on 2/27/18 when he participated for 1 toss. The Participation Log has no criteria. It lists the task and a check under the day of the month. There is no amount of time or the resident's response to the activity. There was no preference assessment provided. Review of the facility policy for Activity Programs under #6 states Activities reflect the schedules, choices and rights of the residents. An observation at approximately 1:20 PM on 2/27/18 revealed the Maintenance Director looking at the broken blinds covering the large windows in Rooms 101 A, B, C. He stated he had just completed installing new sets of blinds an hour earlier. He stated Resident # 45 had pulled the other sets down. The new blinds he was getting ready to reinstall would be the third set in 1 day. During interviews with the Certified Nursing Assistants assigned to the Secured Unit at approximately 10:30 AM on 2/26 & 27/2018, stated Resident # 45 does not participate in Activities. They stated he likes to go outside the room. They stated he self propels throughout the unit going to each resident ' s room and pulling the blinds from the windows on a continuous basis. They stated this occurs every day. They confirmed they should take a group outside everyday. An interview with the Activities Director on 2/28/18 at 10:15 AM, revealed there was no individualized program for the cognitively impaired Residents # 43 and 45.

Based on file review and interview, it was determined that for 1 (#3) of 2 sampled residents it was determined that the facility failed to ensure that the resident received adequate assistance devices, and supervision to prevent accidents that resulted in a fall in which the resident sustained [REDACTED]. Findings: File review revealed that on 03/05/12, the facility recorded that resident #3 was found in room sitting on the floor; stating that she had been ambulating ad-lib while in room. On 03/07/12 the facility recorded that the resident slid out of the out of the recliner, stating that the resident was attempting to get out of the recliner while the foot rest was up. It was recorded again on 03/09/12 that resident #3 fell out of the recliner. After the 03/09/12. fall the resident was referred to therapy, and was receiving therapy for gait training with emphasis on increasing safety, performance in patient's room; and gait training with emphasis on stride length. It was also recorded that the resident was receiving therapy up until her 04/02/12 fall, when she was discharge to the hospital with facial injuries received from the fall. On 04/02/12, at 11:55 PM, the facility recorded that resident #3 was heard to fall out of bed, and was found face down on the floor. Per interview conducted at approximately 2:30 PM, on 04/17/12, the administrator reported that the resident stood up, lost her balance, and fell . Review of the 04/11/12 hospital discharge summary revealed that the resident presented to the hospital with proximal humerus fracture, and facial fracture; and was discharged with left anterior, and wall fracture of maxillary sinus, orbital floor, lateral wall, right humerus fracture The facility's 02/14/12 quarterly Minimum Data Set (MDS) note recorded the following: Resident #3 requires extensive assist with all Activities of Daily Living Skills (ADLS) due to dementia.; She has poor balance, and requires weight bearing assistance to stand, and transfer.; She is unable to correct her own balance without staff intervention.; and She uses a wheelchair of all mobility. Review of the resident's 03/13/12 full MDS revealed that the resident was coded as requiring supervision with transfers; and ambulation on, and off the unit. Resident #3 was admitted to the facility on [DATE], and the 05/17/11 hospital discharge summary recorded that the resident had a [DIAGNOSES REDACTED]. She was residing on the secured unit, and review of her 03/16/12 care plan revealed that she had a care plan for cognitive loss related to dementia. The care plan also reflected that the facility had identified being at risk for falls as a problem, and developed a goal for the resident to remain free of fall related injury daily. Further review of the care plan revealed that the facility developed the following approaches for achieving the goal : 1. Call light in reach and answer promptly; 2 Re-explain how to use the call light frequently if necessary; 3. Instruct resident to use call light prior to attempting to ambulate or transfer; 4. Wear non-slip shoes or slippers when out of bed; 5. Keep room free of clutter and spills; 6. Grab bar in the bathroom; 7. Assess for activity intolerance; 8. Attempt to anticipate and meet needs; 9 Provide incontinence care after each incontinent episode; 10. Keep fluids with in easy reach; 11. Monitor vital signs as indicated; 12. Monitor for adverse side effects from medications, and report; and 13. Therapy treatment as ordered. No other devices or additional monitoring was identified that would alert staff when the resident did attempt to ambulate, or transfer without using the call light to obtain assistance